Case presentation 2 in psychiatrics.pptx

psychiartry

1. Case presentation DR. LYANNE DEDE SIKA BOATENG RESIDENT

2. BIODATA Madam K.M.I 51 YEARS LIVED IN NIGERIA, MOVED TO GHANA A YEAR AGO MARRIED NURSE NIGERIAN- YORUBA MUSLIM HISTORY RELIABLE SEEN WITH HUSBAND

3. PRESENTING COMPLAINTS EPISODES OF NOT FEELING HERSELF-

4. HISTORY OF PRESENTING COMPLAINTS Ms. C was in her usual state of health until 5 days prior to presentation when she started to feel like her body and her feelings were not for her. She feels like in a dream and feels like she is not alive, sometimes she has to ask her cousin to pinch her to make sure she is alive . She is confused whether objects around her or actions of people are real hence she keeps asking her cousin to verify for her if what she is feeling is actually real. She cannot feel food in her mouth when eating, she cannot smell, was crying and didn't know she was crying and gets confused sometimes with time and hence will ask cousin what day it was. She has been stressed out in school as she had to stay behind to do production in school. She cannot concentrate in school and is affecting her studies, she went to the Medifem hospital where she was subsequently referred to this facility for further management.

5. ODQ Hearing voices in clear consciousness-, Seeing images-,Neglect of personal hygiene-,Social withdrawal-, aggression-, mutism +, irrelevant talk-, irrelevant talk- Sadness-(> 2weeks), Crying spells+(3 days), Loss of interest in activities previously enjoyed+, Suicidal thoughts-, Low energy-,Hopelessness-,Worthlessness-, suicide thoughts-, guilt feelings-, low energy+(3 days), poor sleep-, poor concentration+, low appetite+, weight loss-, feeling of slowness(4 days) elation-, over generosity- , hyper sexuality, fear- feels something is going to happen to her+, palpitations-, sweaty palms-, anxiety-

6. Systemic enquiry Fatigue-, lethargy-, heat intolerance-, brittle hair and nails- CNS- Slurred speech-, weakness-, trouble walking- or balance

7. pphx She had her first episode about 4 years ago, in her final year in secondary school. At the time she had an episode of not feeling like herself, seeing things not seen by others and hearing voices inaudible to others. She remember just screaming and was having a hard time recognizing people. Her mother took her to the hospital nothing was done for her as she was told there is nothing wrong with her, the symptoms resolved completely after a week. About 2 years ago the symptoms of not feeling herself and feeling like she's living in a dream, she was just at home and symptoms resolved after she was just at home and symptoms resolved after 5 days.

8. FURTHER PMSH- NIL OF NOTE DH- NIL OF NOTE ALLERGIES- NIL OF NOTE

9. FAMILY HISTORY Mum- 40years,used to a trader, father - doesn't know him. Divorced in class 5/6 Only child of both parents FHxpositive (high fever- paternal) FHX OF MENTAL ILLNESS-, CHRONIC ILLNESS-

10. PERSONAL HISTORY PREGNANCY AND DELIVERY: SVD at TERM and uneventful CHILDHOOD: Uneventful EDUCATION: Started school at age 1, completed Sammy Otoo SHS as a business student. A ggregate- 15 currently reading theatre arts and information studies in the University of Ghana, Legon , level 400 GPA- 3.06.

11. PERSONAL HISTORY EMPLOYMENT : Has been working as a mason/building contractor since he dropped out of school up until 2016 when the company he was working with stopped receiving contracts. He’s currently working on a building project for a relative. PSYCHOSEXUAL : Heterosexual . Sexual abuse-. Coitache -: not yet, has never been in any romantic relationships (tried in his late 30’s however the lady was not interested, also he has never met anyone he sees as extremely beautiful yet) and currently has no desire to do so. Does not have any children

12. FURTHER HISTORY SOCIAL HISTORY Grew up with parents in Teshie , currently stays with his 12yr old niece in the family house made up of different single roomed apartments. DRUG HABITS: Alcohol+, Smoking- FORENSIC HISTORY: NIL PREMORBID PERSONALITY . Introvert, very reserved Hobbies- playing card games Christian- Jehovah’s Witness Coping mechanism- confides in friend.

13. General examination Stable elderly man, jaundice -, pallour-, clubbing -, pedal oedema -, afebrile Temp-36.4*c, FBS- 6.7mmol/l Abdomen: No spider nævi, non distended MWR, Soft, non tender ,2k* L* S* CVS: P-76bpm, BP- 134/79mmHg ,HS1+2 , M* RS: RR- 12cpm BS- vesicular , AE; adequate bilaterally

14. GENERAL EXAM CNS Steady gait GCS- 15/15 Bilateral fine digital tremors Cranial Nerve Exam, normal. Reflexes normal, pupils are 3mm bilaterally and reacts normally and consensually to light No facial asymmetry Tone and reflexes all normal . Power 5/5 in all limbs Babinski normal, clonus normal . .

15. MENTAL STATE EXAM APPEARANCE Neatly and appropriately dressed in a brown shirt and jeans trousers with black sandals .Nails and hair well kempt. No malodorous smell, no visible scars or tattoos. BEHAVIOUR Cooperative, sat uprightly , Calm and maintained eye contact. Established good rapport Normal Gait SPEECH S pontaneous, normal tone, rate and volume, coherent and relevant.

16. MSE MOOD Normal AFFECT Euthymic, reactive. PERCEPTION No auditory, visual, auditory Hallucinations.

17. MSE THOUGHT Stream: Normal Form: Linear and goal directed. Content: N o persecutory, grandiose or delusions of reference, no suicidal ideations Thought possession: Withdrawal -, insertion -, broadcast – Control: Passivity Phenomenon -

18. mse PERCEPTION No auditory, visual, auditory hallucinations COGNITION ORIENTATION: Time+, Place+, Person+ ATTENTION: Good CONCENTRATION : Impaired (Days of the week ) MEMORY Long term- intact Short term- impaired (ADDRESS ) Immediate : 2/3, 5-mins recall- 1/3

19. MSE ABSTRACT THINKING: Good(proverb interpretation) JUDGMENT: Good LEVEL OF KNOWLEDGE – Good INSIGHT: Good

20. FORMULATION 66 year old Mr. S.K.O presented this facility 2 weeks ago with a 56 year history of chronic alcohol use w hich started with about 1.2 units of alcohol( akpeteshie ) monthly and has steadily increased over the past 8 years to over 8.6unit of a lcohol daily . He is dependent on it and desires to quit drinking but has had several failed attempts. He also has a 3 months history of forgetfulness as he is unable to remember very recent happenings but remembers important events in his past. On physical examination there he had fine tremors in both hands. Mental examination revealed impairment in memory and concentration, he however has a good insight into his condition.

21. ITEMS OF PHENOMENOLOGY Has a strong desire to take alcohol. Experiences withdrawal symptoms(palpitations, night sweats, tremors). Tolerance Persistent use despite evidence of consequences. Memory Loss Impaired concentration and memory Fine digital tremors at rest.

22. impression ICD 10 MULTIAXIAL DIAGNOSIS AXIS I- CLINICAL DIAGNOSIS Alcohol dependence with alcohol-induced persisting amnestic disorder. (F10.26 ) Stage of change: Preparation. Hypertension

23. DIFFERENTIAL DIAGNOSES VASCULAR DEMENTIA NORMAL AGING STROKE SCHIZOID PERSONALITY DISORDER

24. AXIS II-DISABILITIES Personal Care -1 Occupational functioning- 3 Functioning with family -1 Functioning in a broad social context- 1

25. AXIS III CONTEXTUAL FACTORS BIOLOGICAL PSYCHOLOGICAL SOCIAL PREDISPOSING FAMILY HISTORY OF ALCOHOL USE MOTHER OWNING BAR PRECIPITATING UNEMPLOYMENT PERPETUATING PROTECTIVE GOOD GENERAL HEALTH GOOD INSIGHT SOCIAL SUPPORT

26. MANAGEMENT SETTING OUTPATIENT DEPARTMENT .(<15 UNITS DAILY, NO SEIZURES, NO SEVERE MALNUTRITION, NOT VULNERABLE) GOALS SHORT TERM -Detoxification -Manage thiamine deficiency LONG TERM -Long term cessation and stabilization

27. INVESTIGATIONS

28. MANAGEMENT(SHORT TERM)

29. MANAGEMENT(long TERM)

30. PROGNOSIS ALCOHOL DEPENDENCE BAD PROGNOSTIC FACTORS- Long duration of alcohol use, dependent drinker GOOD PROGNOSTIC FACTORS Good insight, male gender OVERALL PROGNOSIS GUARDED AMNESIC DISORDER BAD PROGNOSTIC FACTORS- Poor diet GOOD PROGNOSTIC FACTORS Early treatment

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